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Wednesday, April 11, 2012

3 Months Isn't Enough!

Three months is the standard maternity leave in the U.S. Most states will give 12 weeks of family leave, paid or unpaid (often unpaid). A lot of women, especially those in medicine, especially those in medical training, take less. *raises hand*

The reasons women go back to work very early include:

1) Loss of income

2) Fear of missing training/schooling

3) Pressure from peers

4) Fear of loss of job

Some women will cite "boredom" as a reason for going back to work early, but I honestly don't believe that if all the other factors were eliminated, they would make the same choice.

I'm going to go out on a limb and say that three months isn't enough. I'm not the kind of woman who wants to stay home indefinitely, but three months is just way too short. Six months is more like it.

Here's why:

1) Unless you have an amazing support system, you're still a mess at three months. Yes, your baby is supposed to sleep through the night at this point, but did you know that "sleeping through the night" is actually defined as sleeping five hours in a row? And that humans should be getting at least eight hours of sleep per night? So unless you're a dolphin or something, you're waking up at least once per night. You're not even close to functioning at full capacity, likely making lots of mistakes.

2) In all honesty, having done it myself, I feel like three months is too young for a baby to be in daycare. Babies that age need a lot of attention and it's so pathetic how they just lie there and can't really interact on their own. By six months, they're sitting up and almost crawling, so it's not so bad. Plus daycare is a vector for disease that their immature immune systems can't handle as well, so you're guaranteed to get lots of "pick up sick kid" calls, which further decreases your work reliability. Of course, a lot of women opt for a nanny, but that's its own set of problems.

3) The recommendation is to give breastmilk exclusively for the first six months, but that is no easy task to accomplish when you're working full time. It either puts even more strain on your employment or causes you to give up.

4) I personally felt like I wasn't emotionally ready at three months to leave the baby. Maybe that's not a good reason. Or maybe it's the only good reason.

I guess I only came up with four reasons, but I think they're four really good reasons. Unfortunately, the reasons for going back early are even more compelling.

Why are the only two options a) go back full time and work 60-80 hours per week immediately, and b) stay home full time?

I personally couldn't wait to go back to work/school (I went back after 8 weeks), but I also am in grad school and have a very flexible schedule and have been able to ease back into it. I actually don't think I realized just how miserable I was staying home full time until I went back for that first meeting about a month ago.

I am probably working about 40 hours per week now, not including time to pump / breastfeed. (I also worked over maternity leave, but that's because I'd prefer to work while my baby nursed than to watch tv or do nothing). It's been more or less ideal for me. It's too bad more people don't have this option, because I think many people would be happy to be back doing some sort of work at 8 weeks if they had the support system (and the right job). Just not 80 hours of it.

Because people in this country don't want to pay for it through higher taxes? Many think, "Why should we be subsidizing maternity leave when women should just quit their jobs to be home with their kids?"

I have been thinking a lot about this lately as 2 of the 4 doctors in my group are currently pregnant. Let me be clear that I am exstatic for both of them and I am happy to cover for them while they are on leave.... but the next 6 months are going to be EXTREMELY challenging. Both are planning to only take 6 weeks off, but the call and financial burden this is going to place on our group will be large. We are a private practice and we own our own business our overhead is tight, so we really can't afford to bring in locums. I will most likely not get vacation or time off for 6 months while I am covering.

Yes in an ideal world taking a longer time off would be ideal. But its not realistic in most settings.

When we take maternity leaves we still have to pay our overhead : rent, employees, malpractice, ect. For a private practice OB to take 3 months off they would need at least %120, 000 just to cover overhead. Is it really realistic to ask the government or other to pay that?

RH: Well, what do countries like Canada do, where women get a year off?

I'm not suggesting I know what the solution is. But I do think that three months is not enough time and six weeks is just ridiculous, especially if you're going back to a busy OB/GYN practice. Do patients get worse care as a result? Probably. Does the baby get optimal care? Probably not.

Maybe someday, much like with the Bell Commission, a female physician will come back to work at 6 weeks and make a tragic error, and then maybe some changes will result. What changes? I don't know.

I completely agree with your post Fizzy. A number of my friends have taken maternal/paternal leave here in Canada during residency, and having up to a year off has been a really good thing for them and their kids. They actually get to enjoy some of their kids' infancy and to be present for many of the important milestones, rather than at the hospital wishing to be home. And because 6-12 months is a fairly standard parental leave for residents, there isn't a stigma against it or a sense that residents are missing out on their training. They just go back to where they left off when the leave ends and extend their residency so they get the same amount of training as everyone else.

As for how it's paid for, in my province a portion of the parental leave costs are paid by our employment insurance system (which pays all parents on parental leave) and the remainder are paid by the local medical association out of member dues. For overhead, I imagine it varies from practice to practice. Most practices charge overhead as a percentage of physician revenues, so the overhead would go to little or nothing when the parent isn't working. I think most clinics make up for the gap in overhead fees by charging more than is necessary (i.e. creating a reserve fund) and by having the remaining practice members work longer hours to cover for the person on parental leave (which is entirely feasible when there are 5-10 docs in a given practice).

Are there any local or national residency associations in the States that are advocating for longer parental leave? My province has only had good parental leave benefits for the past 5-10 years, and they only came into place because a group of committed residents (male and female) fought to have up to a year of parental leave included in our union contract.

RH: I was just thinking about the situation you mentioned and I have a question for you. You're in a physically demanding profession... what if it gets to be too much for one or both of your colleagues and they need to go on bedrest for an extended period of time? What if one of them has to take 6 weeks of absolute bedrest... what would she then do about maternity leave? (Presumably the answer is not to come back to work the day after delivery.) What if there are complications with the delivery or newborns that require them to take significantly more than the 6 weeks? What would your practice do? Would you just sink?

I swear, I'm not asking these questions to be a snarky bitch. I am asking respectfully and I am genuinely curious to hear your answers. It sounds like things are spread tight in your practice, so I'd guess it's something you may have thought about, considering you know better than anyone about possible complications. I feel like half the female physicians I know ended up on bedrest during their pregnancies.

One of the reasons I moved back to Canada from the US for med school and beyond was maternity leave.

As described above, taking maternity (or parental if you're a father/partner/adoptive parent) DURING RESIDENCY is relatively easy and at least partially paid.

Once you're done residency it's a completely different story. Even in Canada most physicians I know take only about 3 months. Many are essentially "self-employed" and therefore aren't eligible for the same government maternity leave as any true "employee" would be. There are group insurance-type plans that you can buy into but they're quite expensive. We also need to find someone to cover our practice which is just as difficult as it is in the US.

It's better up here for sure but it's far from perfect... but to me it's worth it to have a career I love AND a wonderful family.

I hope it works out for you, RH. But honestly, that situation sucks and it's not uncommon in medicine. Sometimes I wonder if premeds truly understood some of the sacrifices they'd have to make, they might choose differently. But I guess that's a whole other discussion.

To add to SD and JustMe's comments about the situation in Canada - in my province, the residency association will top up our government employment insurance to 85% of our salary, which is a bit below $50 000/yr, for the first 17 weeks. After that, we can stay on leave categorized as "parental leave" for the remainder of the year, however during those 35 weeks I believe we receive just the standard government EI rate, which is around 40% of salary up to a max of in the $40 000/yr range, so around $1600/month.

In BC, through the provincial physicians' association, after practicing for a year you can receive maternity benefits of $1000/week for up to 17 weeks. As mentioned before usually physicians are self-employed and don't qualify for the government EI as we do as residents, so this could be a tight financial situation if you are covering overhead as well.

Solitary Diner - in BC at least, from my understanding if you're billing the public system, MSP, it would be difficult and illegal to "charge more than is necessary" to make up the difference in the overhead cost to the remaining partners while one is on leave, because every visit is coded to a specific value down to the cent.

Based on my anecdotal discussions, in Canada many attendings and residents view residency as the more advantageous time to have children, and as a resident who is hoping for children during residency I'm thankful for the current environment. I've even heard of a male surgery resident taking a few months of paternity leave.

This is an interesting comparison of benefits across Canada from our residency matching program, CaRMS:

I feel like the most blessed medical student in the world. I'd made plans to spend a 5th year of medical school getting an MPH between my 2nd and 3rd year and it happens to be all independent work which allow me to be at home. I happen to be due to deliver in time to give me 11 months at home with the baby before returning to rotations. Granted I will be doing graduate work, but again, I think it's such a blessing.

I'm a first-time mom, 20 weeks pregnant, starting pathology residency in July, and due September 2nd. First of all, this wasn't "supposed" to happen just yet (we tried for 6 months earlier in the year and failed--so I was incredibly surprised to get a positive test 2 days after my last interview when we weren't even trying), but my program director and chief have been as supportive as I could have hoped for. I will join the 'Six Weeks Off' club so I can finish residency on time without having to give up future years' vacation time, and I am already insanely jealous of everyone who qualifies for FMLA or any other extended leave because they have a regular job (as apparently inadequate as three months off is).

I will not have a single vacation day for the remainder of my first year of training, and will accumulate just one sick day a month until next July. Here's hoping everyone's immune system holds up!!

I agree that 12 weeks is too short for maternity leave. I took 6 weeks and was practically asleep for the next 12 weeks while I tried to juggle breastfeeding/newborn/make-up call/tests/research etc. But I can't imagine taking off a year during my training. A longer maternity leave appeals to me but trying to relearn/refresh/catch up everything a year later might be just as stressful as returning earlier and not missing as much training. Don't get me wrong, I wish I had more time with my daughter after she was born...but I didn't sign up for long hours/call and 12 years of post-graduate training because it was a family-friendly profession. Of course, that doesn't mean we can't strive to make things better....I think the person who suggested returning to work part-time after maternity leave is on to something.

I personally agree that 3 months is not enough...for me. I know everybody is different. But it certainly would be nice to have the option to take 6 months off, and be 'supported' by our peers/departments etc. As a Canadian, and a family physician trained in Canada, my point of view seems to be so different from that of my peers here in Houston. I took 6 months off after my son was born, 3 months paid, 3 months unpaid and boy it was difficult for me to get those 3 months unpaid leave without them firing me. I was made to feel guilty, and at the same time I felt patronized whenever I said I just wanted to be able to spend time with my newborn and that I couldn't pump given my busy schedule. (there realy was no time for me to pump in the clinic I work in)I don't like the way medicine is evolving in general. I didn't go into medicine because I liked business. I truly went into med because I love to care for people. I was constantly told that 'Dr. so-and-so, you have to understand, we are running a business here...', and as much as understand that medicine is a business especially here in the US, I don't F#$#@!n care because frankly I'm just sick of hearing it.

I'm going to have to be the dissenting voice here. Or at least emphasize, as others have, that everyone is different. I took 12 weeks, and it was exactly the right amount of time-- for me. 6 weeks would have been too short. But at 12 weeks, I had a stock of frozen milk, my child was sleeping 12 hours a night (sorry), and, frankly, a 3 month old isn't very interesting (though much more interesting than a 1 month old) for hours at a time. In truth, I went in to work for a couple of hours a couple of times a week (with my baby) starting when she was about 2 weeks old.

Of course, I was 38, an academic anesthesiologist, and 6 months from going up for tenure. So we could afford a full time nanny (allowing our child to sleep until 8 no matter when we left) and lots of people to help us around the house. And I really really love my job, which made going back feel like a vacation not an imposition.

I completely agree that 3 months is not enough. Our little guy wasn't even close to sleeping through the night at that stage. Luckily, I have a very supportive boss who allowed me to come back part-time at that time. I truly appreciated the easing back in. By the time the baby was 6 months old I felt much more ready to be back full time. I think so much of this depends on your work setting. We have a group of (mostly women) pediatricians. We essentially take turns being on maternity leave and support each other by covering call, etc. The norm in the group is to actually take more like 4-6 months of leave (although much is unpaid, so this doesn't work for everyone). I think so much depends on the culture in the workplace.

I am at the end of my second maternity leave. I had 2 kids in the last two years while doing intern year in medicine and first year of radiology. My first baby was a "7 week baby" right before I started intern year. I managed to breastfeed her for 1 year, although I did not perform to my standards during intern year. My second baby is also a "7 week baby" + 1 week bed rest. I feel terribly guilty for taking 2 "extra" weeks off from residency and even though our chiefs are incredibly supportive, I am terrified of what my co-residents are "truly" thinking of my taking 2 whole months for maternity leave/bedrest. I am also not ready to go back to work in a few days. I need more time with my children, but unfortunately this will not happen. I will be back reading films in a dark room after sleepless nights. There will be lots of coffee involved and luckily my freezer is stocked with breastmilk. I will also work my hardest to perform up to my standards - hopefully it will be different this time. Why will I do this? Because I love my job, I love my residency, and the hope that one day my children will be proud of their mommy for achieving her dreams. Would I change anything? Yes, there needs to be an option for women to choose how much time they need to spend with their newborns. We each know how much time we need with our particular children. And I am not even asking to be paid during the time off. I would be happy with an option of unpaid time off without the repercussions of loosing my job. One day this will happen in the USA, unfortunately this is not the time. Why do I believe that this will happen? Women are a very important part of the workforce and by having such unsupportive maternity leave policy we end up loosing a large part of them either through having them come back to work sleep deprived or leaving the workforce all together. By supporting maternity leave, businesses will become open to new employment paradigms (such as share programs, partnerships, exchanges, etc). And in the end, the society will benefit in numerous ways. It is amazing what a mother can do, especially when she is respected to make decisions about her family!

Commenter above - what you are hoping will not happen for reasons RH cited. This country is not like any other in the world. People here resist any "government" involvement without understanding it makes life easier and more pleasant for the rest of the world. And on their own people are forced "to take out a loan" when they need bedrest. (Struck me to my heart, RH, feel sorry for you and your colleagues to be working in such setting).

This conversation has made me thank my lucky stars that I live in Australia. As a doctor-in-training (resident in th US) I am entitled to (and not begrudged) a years leave to be primary care giver. 10 weeks is paid full time, 18 weeks at minimum wage and the rest unpaid. By law I have the option to negotiate part time or flexible work on my return. Our system is not perfect by any means, but sounds like a big step up from yours.

Marley - Sorry to be unclear. When I spoke of "charging more than necessary" I was referring to the overhead fees that physicians pay to their office/work group. It's my understanding that at least some of the work groups will charge their physicians more than the actual cost of overhead (e.g. 25% of salary when 22% of salary is enough to cover expenses) so that they will have a contingency fund to cover expenses when members of the group aren't working as much (e.g. parental leave, sick leave, retirement). It definitely isn't possible to bill the government extra for services!

I am a Canadian physician, and I took 6 months - 17 weeks of which was paid by medical association benefits (2 of those weeks were spend waiting for the Dude to finally make an appearance...), so Dude was 5.5 months when I went back.

My job is in academia, and my division is supportive. I returned part-time for one month, then moved to full-time. Did the pumping thing for months 5.5 to 13.

Anyhow - the difference for me? My husband was able to make use of Canada's benefits to do pat leave from 5.5 months to 12 months, when our son started daycare. It was WAY easier leaving the Dude with my husband. I was totally ready to go back (I actually did a course towards my M.Ed while on mat leave starting at 3 months). The one month of part-time work was a good transition for us, and then we were good to go.

I completely realize this is not an option in many places, but it is totally an option in Canada (the dad taking the bulk of the parental leave - they're allowed 35 weeks) and very few people do it.

Regardless, I was pretty ready for work at 3 months, but I mostly just did my own academic stuff plus the M.Ed course. I did have a sleeper, and a husband who was also fine to get up in the night when breasts were not required. Lucky all around, I realize.

To be clear - if you're self-employed in Canada, you don't get the 12 months, so many self-employed moms, (which is most MDs) are back at work early. In my province, MDs get 17 weeks of much reduced income, but it's a heck of a lot better than none.

However, having the choice to take time vs. not is key here - and the lack of choice is appalling.

My thoughts are with you, Fizzy. I should be doing academic work right now, but I had to respond to this. : )

I firmly believe there is a larger issue at play here. It is not the specific details of our innumerable maternity leave schemes (depending on your state, your industry, your employer, etc.), but the overall treatment of women and children in our society.

Here in the US we systematically devalue women and children. No, I am not some raging feminist, but I have had the benefit of living in Europe (not just being a tourist) and nowhere have I felt like women and children were relegated to a secondary position to the extent they are here in the US.

A priori, women have to keep proving themselves, as if constantly saying "Please master, do not send me away! Thank you master, for allowing me to be here!" in most industries.

I am not someone who could be a SAHM for very long at all. I went back to school 2 weeks after each child, but I was lucky to have uncomplicated births and healthy babies, to be an undergraduate and then a graduate student with incredible flexibility and a husband with a good job. However, I am more than willing to support women who need more time, especially if they are in inflexible situations. Yes, I am willing to put a percentage of ALL my earnings towards helping our society care for our mothers and children. However, my personal ethos seems to go against the growing trend of "Why should I have to take care of someone else? Why should MY money go to help some woman who chose to get pregnant? Why should I have to contribute to somebody else's babies?" (and these are very benign statements, the actual vitriol I have seen/heard many people direct at mothers and children is too hateful, crass and shocking to recount).

We set up Medicare for older people and ESRD patients, because older people (and 43 y.o. white men appearing to have a life out of a Rockwell painting until ESRD hit them, ref. Shep Glazer) have importance in our society (read: they have most of the money and they vote). Yet, we cannot set up a system to take care of our mothers and babies that is worthy of a developed nation.

I was surprised to read about two things- one is that official maternity time off in the US is 3 months - somehow I thought that it was mere 6 weeks.....Maybe because that what my residency offered me the first time around....Another thing I was surprised about - somebody posted that these 6 weeks in residency don't prolong your residency??? In my case ( or maybe it's just my residency?) it did indeed prolong my residency by 6 weeks.... Not that matters to me but still....

I do think that there are moms who are ready and want to go back to work at 3 months: those with great support systems or who have jobs with flexible hours. Even if you ordinarily love your job, you're probably not going to love it so much if you're dropping your infant off at a daycare where they get sick once a week, you don't have a minute in your day to pump, you're exhausted because you were awake during the night feeding the baby, and you're scrambling to get out of work in time for pick-up. Not an unusual situation at all in medicine, unfortunately.

WhiteCoat: YES! Can't agree more.

Most recent anon: In many residencies, you are allowed to miss 6 weeks in a given year for medical or family reasons and not have to make that time up. That was the case in my residency. FMLA allows 12 weeks, but a lot of women take 6, possibly because that's when the first postnatal appointment is so you're expected to be "healed" by then.

I feel like you all are living on a different planet. I am a surgery resident, and I got exactly four weeks. When my baby was less than a month old, I was back in the trauma bay- and while many of you blithely cite "80 hour weeks," the truth of the matter is that nearly all of you are in medical specialties where your hours rarely ever approach that. I am on transplant surgery right now with q2 call and 40+ hour shifts, and I had absolutely no choice in the matter. No option to voluntarily prolong my residency and take unpaid leave. I have a 7wk old son whom I spend every non-hospital minute with.

And in case you're curious,I don't feel 4 wks is enough! And do you seriously think I can pump breast milk every three hours? I'm lucky if I can do it q6.

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